Estimation of Ischemia Modified Albumin (IMA) Levels in Patients with Acute Coronary Syndrome.

Myocardial ischemia produces free radicals that catalyze a series of oxidative reactions that damage healthy tissues. The N-terminal sequence of albumin is one of the proteins modified by these highly reactive oxygen species and forms the ischemia modified albumin (IMA). This study involves investigations undertaken in different study groups to assess the levels of IMA. Mean serum IMA levels (U/mL) in patients with ST-segment elevated myocardial infarction (92.1 ± 10.6), non-ST-segment elevated myocardial infarction (87.3 ± 5.95) and unstable angina (UA) (88.9 ± 6.16) were significantly higher than non-cardiac chest pain (77.9 ± 6.69) and also healthy subjects (54.7 ± 17.2) (p < 0.001). IMA is a highly sensitive marker and has a high predictive value, which might prove the usefulness of this biomarker for early detection of myocardial ischemia. These data indicate a possible role of the IMA test in the early triage of patients with chest pain.

Hybrid stage I palliation for hypo-plastic left heart condition without a hybrid suite: suggestions for developing nations.

Cardiac hybrid procedures are performed in modern, spacious, and highly equipped hybrid suites in developed countries. Organizing such expensive suites in countries with an emerging economy is difficult from both a financial and logistics point of view. We share our experience of safely performing a Hybrid stage I palliation procedure for Aortic atresia with ventricular septal defect on a 2-month-old infant weighing 3.35 kg using minimal resources in a conventional catheterization laboratory.

Pregnancy associated plasma protein-A (PAPP-A) as an early marker for the diagnosis of acute coronary syndrome.

AIMS AND OBJECTIVES: Pregnancy associated plasma protein-A (PAPP-A), a metalloproteinase plays a pivotal role in the pathogenesis of atherosclerosis. Recent studies have reported that elevated levels of PAPP-A, signal the onset of acute coronary syndrome (ACS). We, therefore, proposed to study the analytical competence of PAPP-A in patients admitted to the emergency department with chest pain and finally diagnosed as ACS. METHODS AND RESULTS: Pregnancy associated plasma protein-A was measured using enzyme-linked immunosorbent assay (ELISA) in 485 patients admitted to emergency care unit, of which 89 patients were diagnosed as Non-cardiac chest pain (NCCP). Elevated levels of PAPP-A were observed in patients diagnosed as ACS on comparison with the controls. Receiver operator characteristic (ROC) curve analysis showed PAPP-A to be a good discriminator between ischaemic and non-ischaemic patients. The area under the curve was found to be 0.904, 95% CI (0.874-0.929) with 90% sensitivity and 85% specificity (P< 0.0001). The cut-off value from the ROC curve was 0.55 µg/mL above which PAPP-A was considered to be positive. CONCLUSION: Pregnancy associated plasma protein-A seems to be a promising biomarker for identification and risk stratification for patients with ACS.

WITHDRAWN: Humanised substitutes for animal sera in human mesenchymal stem cell culture and differentiation.

This epub Ahead of Print has been withdrawn by the Publisher.

Absent pulmonary valve syndrome: prenatal cardiac ultrasound diagnosis with autopsy correlation.

Absent pulmonary valve syndrome (APVS) is a rare conotruncal anomaly consisting of a severely hypoplastic pulmonary valve with annular stenosis, aneurysmal dilatation of main pulmonary artery with dilatation of one or both pulmonary artery branches, and a ventricular septal defect. Here, we report a prenatal echo diagnosis of APVS in a 27-year-old primi gravida at 20 weeks of gestation confirmed on fetal autopsy. A 'bow tie'-like hypoechoic shadow in fetal cardiac ultrasound observed by us in a modified four-chamber view was suggestive of aneurysmal dilatation of branch pulmonary arteries. The consequences of continuation of pregnancy including immediate neonatal complications and possible medical and multistaged surgical interventions were well explained. Parents opted for medical termination of pregnancy. Autopsy findings of the fetus were consistent with the prenatal echo diagnosis of APVS. The presence of patent ductus arteriosus seen in the autopsy may be the cause of severe heart failure evidenced by the abnormally large congested liver, dilated right heart chambers, and tricuspid valve annulus. We infer that the prenatal diagnosis of APVS may be possible with a high degree of accuracy with characteristic fetal echocradiographic findings such as 'bow tie'-like or 'ballooning'-like shadows observed in this case. The presence of ductus confirms definite fetal loss and the parents can be counselled accordingly. However, when the ductus is absent, decision-making is difficult as the fetus is going to survive.

Plasma total nitric oxide and endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphism: a study in a South Indian population.

In an analysis of the possible association of endothelial constitutive nitric oxide synthase (ecNOS) gene polymorphism and plasma nitric oxide levels in patients with acute coronary syndrome, we investigated 106 patients with the syndrome and 100 healthy controls. Genotype was determined using the polymerase chain reaction; plasma nitric oxide levels were found using ELISA. The genotype frequencies for the a/b polymorphism in the control group were 77% for bb, 19% for ab, and 4% for aa. In the patients, genotype frequencies were 55% bb, 34% ab, and 11% aa. The allele frequencies were 28% a and 72% b among the patients and 13% a and 87% b among control subjects. Our findings showed a significant association of the ecNOS gene polymorphism with acute coronary syndrome in the South Indian population.

Off-pump trans-apical trans-catheteraortic valve implantation: first successful case report in India.

Trans-catheter aortic valve implantation has emerged as an alternative to conventional aortic valve replacement for patients with symptomatic severe aortic stenosis considered to be at very high or prohibitive operative risk. We report the first successful Off-pump trans-apical trans-catheter aortic valve implantation in India for a case of severe calcific aortic stenosis with a Logistic Euroscore of 20%.

Statistical tools for analysing the data obtained from repeated dose toxicity studies with rodents: a comparison of the statistical tools used in Japan with that of used in other countries.

In the present study, an attempt was made to compare the statistical tools used for analysing the data of repeated dose toxicity studies with rodents conducted in 45 countries, with that of Japan. The study revealed that there was no congruence among the countries in the use of statistical tools for analysing the data obtained from the above studies. For example, to analyse the data obtained from repeated dose toxicity studies with rodents, Scheffé's multiple range and Dunnett type (joint type Dunnett) tests are commonly used in Japan, but in other countries use of these statistical tools is not so common. However, statistical techniques used for testing the above data for homogeneity of variance and inter-group comparisons do not differ much between Japan and other countries. In Japan, the data are generally not tested for normality and the same is true with the most of the countries investigated. In the present investigation, out of 127 studies examined, data of only 6 studies were analysed for both homogeneity of variance and normal distribution. For examining homogeneity of variance, we propose Levene's test, since the commonly used Bartlett's test may show heterogeneity in variance in all the groups, if a slight heterogeneity in variance is seen any one of the groups. We suggest the data may be examined for both homogeneity of variance and normal distribution. For the data of the groups that do not show heterogeneity of variance, to find the significant difference among the groups, we recommend Dunnett's test, and for those show heterogeneity of variance, we recommend Steel's test.

PROSE: Prospective Randomized Trial of the On-X Mechanical Prosthesis and the St Jude Medical Mechanical Prosthesis Evaluation : Part 1(Patient Dynamics): Preoperative demographics and preoperative and operative risk factors.

OBJECTIVES: The PROSE trial purpose is to investigate whether the incidence of thromboembolic-related complications is reduced with a current generation mechanical prosthesis (On-X Life Technologies/CryoLife Inc.-On-X) compared with a previous generation mechanical prosthesis (St Jude Medical-SJM). The primary purpose of the initial report is to document the preoperative demographics, and the preoperative and operative risk factors by individual prosthesis and by Western and Developing populations. METHODS: The PROSE study was conducted in 28 worldwide centres and incorporated 855 subjects randomized between 2003 and 2016. The study enrollment was discontinued on August 31, 2016. The preoperative demographics incorporated age, gender, functional class, etiology, prosthetic degeneration, primary rhythm, primary valve lesion, weight, height, BSA and BMI. The preoperative and operative evaluation incorporated 24 risk factors. RESULTS: The total patient population (855) incorporated On-X population (462) and the St Jude Medical population (393). There was no significant difference of any of the preoperative demographics between the On-X and SJM groups. The preoperative and operative risk factors evaluation showed there was no significant difference between the On-X and St Jude Medical populations. The preoperative and operative risk factors by valve position (aortic and mitral) also documented no differentiation. The dominant preoperative demographics of the Western world population were older age, male gender, sinus rhythm, aortic stenosis, congenital aortic lesion, and mitral regurgitation. The dominant demographics of the Developing world population were rheumatic etiology, atrial fibrillation, aortic regurgitation, mixed aortic lesions, mitral stenosis and mixed mitral lesions. The Developing world group had only one significant risk factor, congestive heart failure. The majority of the preoperative and operative risk factors were significant in the Western world population. CONCLUSIONS: The preoperative demographics do not differentiate the prostheses but do differentiate the Western and Developing world populations. The preoperative and operative risk factors do not differentiate the prostheses BUT do differentiate the Western and Developing world populations.

Heart fatty acid binding protein (H-FABP) as a diagnostic biomarker in patients with acute coronary syndrome.

AIMS AND OBJECTIVES: Diagnosis of myocardial ischaemia at an early stage in the emergency department is often difficult. A recently proposed biomarker, heart fatty acid binding protein (H-FABP) has been found to appear in the circulation superior to that of cardiac troponins in the early hours of acute coronary syndrome. We proposed to evaluate the levels of H-FABP and ascertain its utility as an early biomarker for acute coronary syndrome (ACS). METHODS AND RESULTS: The present study was carried out in 485 subjects, of whom 297 were diagnosed as patients with ACS, 89 were diagnosed as non-cardiac chest pain (NCCP) and 99 people served as healthy controls. H-FABP levels were measured in comparison with standard markers such as troponin I and CK-MB in all subjects enrolled in the study. The levels of H-FABP were significantly raised in patients when compared to controls and NCCP (P<0.001). Receiver Operator Characteristic Curve (ROC) analysis showed H-FABP to be a good discriminator between patients with ischaemic heart disease and patients without ischaemic heart disease. The area under the curve was found to be 0.965 with 95% CI (0.945-0.979). The cut-off value above which H-FABP can be considered positive was found to be 17.7ng/ml. CONCLUSION: H-FABP is a promising biomarker for the early detection of patients with acute coronary syndrome.

Lipid profile and non-enzymic antioxidant status in patients with acute coronary syndrome in South India.

AIMS AND OBJECTIVES: Elevated lipid profile and reduced antioxidants accelerate the formation of atherosclerosis. Multiple lines of evidences have suggested that increased lipids and low antioxidants are the major risk factors for the incidence of acute coronary syndrome. Oxidative stress evaluation is now considered as an index for the assessment of development of coronary artery disease. Therefore, we studied association of the levels of non-enzymic antioxidants and lipid profile in controls and patients with acute coronary syndrome (ACS). METHODS AND RESULTS: The present study was carried out on 485 patients admitted to the emergency care unit, of whom 89 patients were diagnosed as non-cardiac chest pain (NCCP). Total cholesterol, LDL-cholesterol, HDL-cholesterol and triglycerides were analysed along with non-enzymic antioxidants such as vitamin C, vitamin E, reduced glutathione, MDA and protein thiol in controls and patients with ACS. The levels of total cholesterol and LDL-cholesterol were significantly raised in patients when compared to controls in contrast to lowering of HDL-cholesterol levels in patients than controls. Vitamin C, vitamin E, reduced glutathione, MDA and protein thiol levels were significantly lowered in patients than controls (p<0.05). CONCLUSION: Oxidative stress and lipid profile should be included as important markers in the early detection of acute coronary syndrome.

Urinary 8-OHdG: A marker of oxidative stress to DNA and total antioxidant status in essential hypertension with South Indian population.

Establishment of non-invasive urinary biomarker for the early prediction of essential hypertension (EH) is important. We evaluated whether estimation of urinary DNA, serves as a marker to predict the extent of cellular oxidative stress in essential hypertension. A total of 180 South Indian subjects aged 30-65 were recruited for the study. Of these hypertensive subjects investigated, 30 were newly diagnosed and were not on any antihypertensive drugs, but had systolic blood pressure 140-160 mmHg and diastolic blood pressure 95-100 mmHg and 75 hypertensive patients who already on drug therapy for one year and 75 were South Indian normotensive healthy controls with blood pressure ≤ 120/80 mmHg. The 8-OHdG level in urine was significantly increased in hypertensive patients (both newly diagnosed and who already on drug therapy) compared with control group. The significant increase in 8-OHdG was observed in newly diagnosed hypertensive patients compared with hypertensive patients who already on drug therapy. There was a significant decrease in serum TAS value in essential hypertensive group when compared to control group. The urinary 8-OHdG was independently correlated with serum TAS. Decreased TAS levels, which reflect to increased oxidative stress, may be the reason of increased urinary 8-OHdG in South Indian hypertensive patients. Our preliminary data suggest that the competitive ELISA for 8-OHdG appears to be a simple method for quantifying the extent of oxidative stress.

Osteomyelitis of the rib caused by Aspergillus flavus following cardiac surgery.

Deep sternal wound infections are a rare but severe complication of coronary artery bypass graft (CABG) surgery, with an estimated prevalence of 1%-4%. We report a case of osteomyelitis of the rib and chest wall abscess caused by Aspergillus flavus in a CABG patient, which was treated successfully with voriconazole.

Increased serum concentrations of Soluble CD40 Ligand as a prognostic marker in patients with Acute Coronary Syndrome.

CD40-CD40L interaction plays a significant role in the pathogenesis of atherosclerosis and coronary artery disease. The clinical predictive value of Soluble CD40 Ligand (sCD40L) was evaluated in patients with Acute Coronary Syndrome (ACS) and Non-Cardiac Chest Pain (NCCP). The levels of serum soluble CD 40 ligand were measured by ELISA in 485 patients admitted to emergency care unit, of which 89 patients were diagnosed as NCCP. The levels of sCD40L were significantly increased in patients with ACS when compared to controls and NCCP. Receiver Operator Characteristic (ROC) Curve analysis showed sCD40L to be a good discriminator between patients with ischemic heart disease and patients without ischemic heart disease. The area under the curve was found to be 0.940 with 95% CI (0.915 to 0.960) (P<0.0001). The cut off value from the ROC curve was 2.99 ng/ml, above which sCD40L was considered to be positive. Combined assessment of sCD40L, Troponin I and CK-MB enhanced the risk prediction and early classification of patients. sCD40L seems to be a promising biomarker for identification and risk stratification for patients with acute coronary syndrome.

Linking world bank development indicators and outcomes of congenital heart surgery in low-income and middle-income countries: retrospective analysis of quality improvement data.

OBJECTIVE: Many low-income and middle-income countries (LMICs) struggle to provide the health services investment required for life-saving congenital heart disease (CHD) surgery. We explored associations between risk-adjusted CHD surgical mortality from 17 LMICs and global development indices to identify patterns that might inform investment strategies. DESIGN: Retrospective analysis: country-specific standardised mortality ratios were graphed against global development indices reflective of wealth and healthcare investment. Spearman correlation coefficients were calculated. SETTING AND PARTICIPANTS: The International Quality Improvement Collaborative (IQIC) keeps a volunteer registry of outcomes of CHD surgery programmes in low-resource settings. Inclusion in the IQIC is voluntary enrolment by hospital sites. Patients in the registry underwent congenital heart surgery. Sites that actively participated in IQIC in 2013, 2014 or 2015 and passed a 10% data audit were asked for permission to share data for this study. 31 sites in 17 countries are included. OUTCOME MEASURES: In-hospital mortality: standardised mortality ratios were calculated. Risk adjustment for in-hospital mortality uses the Risk Adjustment for Congenital Heart Surgery method, a model including surgical risk category, age group, prematurity, presence of a major non-cardiac structural anomaly and multiple congenital heart procedures during admission. RESULTS: The IQIC registry includes 24 917 congenital heart surgeries performed in children<18 years of age. The overall in-hospital mortality rate was 5.0%. Country-level congenital heart surgery standardised mortality ratios were negatively correlated with gross domestic product (GDP) per capita (r=-0.34, p=0.18), and health expenditure per capita (r=-0.23, p=0.37) and positively correlated with under-five mortality (r=0.60, p=0.01) and undernourishment (r=0.39, p=0.17). Countries with lower development had wider variation in mortality. GDP per capita is a driver of the association between some other measures and mortality. CONCLUSIONS: Results display a moderate relationship among wealth, healthcare investment and malnutrition, with significant variation, including superior results in many countries with low GDP per capita. These findings provide context and optimism for investment in CHD procedures in low-resource settings.

Tetralogy of Fallot Repair in Developing Countries: International Quality Improvement Collaborative.

BACKGROUND: Isolated reports from low- and middle-income countries (LMICs) for surgical results in tetralogy of Fallot (TOF) are available. The International Quality Improvement Collaborative for Congenital Heart Disease (IQIC) seeks to improve surgical results promoting reductions in infection and mortality in LMICs. METHODS: All cases of TOF in the IQIC database performed between 2010 and 2014 at 32 centers in 20 LMICs were included. Excluded from the analysis were TOF with any associated lesions. A logistic regression analysis was performed to identify risk factors for in-hospital mortality after surgery for TOF. RESULTS: A total of 2,164 patients were identified. There were 1,839 initial primary repairs, 200 with initial systemic-to-pulmonary artery shunt, and 125 underwent secondary repair after initial palliation. Overall mortality was 3.6% (78 of 2,164), initial primary repair was 3.3% (60 of 1,839), initial systemic-to-pulmonary artery shunt was 8.0% (16 of 200), and secondary repair was 1.6% (2 of 125; p = 0.003). Major infections occurred in 5.9% (128 of 2,164) of the entire cohort. Risk factors for death after the initial primary repair were oxygen saturation less than 90% and weight/body mass index for age below the fifth percentile (p < 0.001). The initial primary repair occurred after age 1 year in 54% (991 of 1,839). Older age at initial primary repair was not a risk factor for death (p = 0.21). CONCLUSIONS: TOF patients are often operated on after age 1 year in LMICs. Unlike in developed countries, older age is not a risk factor for death. Nutritional and hypoxemic status were associated with higher mortality and infection. This information fills a critical knowledge gap for surgery in LMIC.

Pseudosequestration of the left lung.

Bronchovascular malformations of the lung constitute a broad spectrum of developmental disorders in which a part of the lung is perfused exclusively from the systemic arterial tree with or without tracheobronchial communication. We report the case of an infant with severe pulmonary artery hypertension whose entire left lung was supplied by collateral vessels from the celiac trunk and the left subclavian artery. The left tracheobronchial tree was normal. Coil embolization of the collateral vessels was performed to reduce the pulmonary blood flow.

Multiple cardiovascular involvement in a case of relapsing polychondritis.

Relapsing polychondritis is a multisystem disease characterized by recurrent inflammation of the cartilaginous tissue. Cardiovascular manifestations of relapsing polychondritis are rare but are the second most common cause of death in these patients. We report a case of relapsing polychondritis who underwent aortic valve replacement uneventfully but presented six months later with myocardial infarction due to bilateral coronary ostial stenosis.